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Allergic rhinitis

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Pathophysiology, diagnosis and management of Allergic Rhinitis

Pathophysiology, diagnosis and management of Allergic Rhinitis

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  • 1. Allergic Rhinitis Dr Sukanta Sen MD, DNB, MNAMS Kolkata, India
  • 2. What is Allergic Rhinitis? Rhinitis is broadly defined as inflammation of the nasal mucosa. Allergic rhinitis is a common disorder that is strongly linked to asthma and conjunctivitis. It is usually a longstanding condition that often goes undetected in the primary-care setting.
  • 3. The scale of the problem Rhinitis is a common disorder that affects up to 40% of the population. Allergic rhinitis is the most common type of chronic rhinitis, affecting 10 to 20% of the population, and evidence suggests that the prevalence of the disorder is increasing. Ref:The Canadian Rhinitis Working Group: Rhinitis: A practical and comprehensive approach to assessment and therapy. J Otolaryngol 2007, 36(Suppl 1):S5-S27.
  • 4. Family history: Children with parents who have allergies or asthma are more likely to be affected. If a child has one parent with allergies, chances are 30% that a child will have allergic rhinitis. This increases to 50-70% if both parents have allergies or atopic asthma. Related medical history: Patients with a history of infantile eczema (atopic dermatitis) have a 70% chance of having allergic rhinitis, asthma, or both. Patients with a history of asthma also have higher incidence of allergic rhinitis.
  • 5. Pathophysiology A. Immediate allergic reaction A-1. Sensitization phase B-1. Challenge phase B. Late phase allergic reaction : inflammation, cellular infiltration, tissue destruction
  • 6. The T cells infiltrating the nasal mucosa are predominantly T helper (Th)2 in nature and release cytokines (e.g., interleukin [IL]-3, IL-4, IL-5, and IL-13) that promote immunoglobulin E (IgE) production by plasma cells. IgE production, in turn, triggers the release of mediators, such as histamine and leukotrienes, that are responsible for arteriolar dilation, increased vascular permeability, itching, rhinorrhea (runny nose), mucous secretion, and smooth muscle contraction. Ref: Dykewicz MS, Hamilos DL: Rhinitis and sinusitis. J Allergy Clin Immunol 2010, 125:S103-115.
  • 7. Classification Rhinitis is classified into one of the following categories according to etiology: IgE-mediated (allergic), autonomic, infectious and idiopathic (unknown). Traditionally, allergic rhinitis has been categorized as seasonal (occurs during a specific season) or perennial (occurs throughout the year). It is now classified according to symptom duration (intermittent or persistent) and severity (mild, moderate or severe)
  • 8. Figure : Classification of allergic rhinitis according to symptom duration and severity. Adapted from Small et al., 2007, Bousquet et al., 2008.
  • 9. Table : Etiological classification of rhinitis Description IgEmediated (allergic) • IgE-mediated inflammation of the nasal mucosa, resulting in eosinophilic and Th2cell infiltration of the nasal lining • Further classified as intermittent or persistent Autonomic • Drug-induced (rhinitis medicamentosa) • Hypothyroidism • Hormonal • Non-allergic rhinitis with eosinophilia syndrome (NARES) Infectious Precipitated by viral (most common), bacterial, or fungal infection Idiopathic • Etiology cannot be determined
  • 10. DDx of non-allergic & allergic rhinitis Non-allergic Allergic Temporal pattern of symptoms perennial seasonal or perennial with seasonal exacerbations Type of symptoms congestion, rhinorrhea, posterior drainage, sinus pressure sneezing, pruritus, congestion, rhinorrhea, posterior drainage, sinus pressure Age of onset 70% are older than 20 70% are younger than 20 Precipitating factors nonspecific irritants specific antigens± nonspecific irritants Other atopic disease not present frequently present Family history of rhinitis not frequent frequent
  • 11. Clinical Presentation AR is characterized by the presence of four classic symptoms: sneezing, itching, rhinorrhea, and nasal congestion.  In addition to these nasal symptoms of AR, patients often present with nonnasal symptoms such as conjunctival irritation, palatal itching, and epiphora as well.  Patients may also describe symptoms such as frontal and periorbital headaches, loss of taste or smell, and pressure and fullness in the ears.
  • 12. Components of a complete history and physical examination for suspected rhinitis • • • • • • • • • • • • • • Personal Nasal itch Rhinorrhea Sneezing Eye involvement Seasonality Triggers Family Allergy Asthma Environmental Pollens Animals Flooring/upholstery Mould Humidity Tobacco exposure
  • 13. • • • • • • • • • • • • • • • • Medication/drug use Beta-blockers ASA NSAIDs ACE inhibitors Hormone therapy Recreational cocaine use Quality of life Rhinitis-specific questionnaire Comorbidities Asthma Mouth breathing Snoring Sinus involvement Otitis media Nasal polyps Conjunctivitis Response to previous medications Second-generation oral antihistamines Intranasal corticosteroids
  • 14. Physical examination • • • • • • • • • • • • • • • Outward signs Mouth breathing Rubbing the nose/transverse nasal crease Frequent sniffling and/or throat clearing Allergic shiners (dark circles under eyes) Nose Mucosal swelling, bleeding Pale, thin secretions Polyps or other structural abnormalities Ears Generally normal Pneumatic otoscopy to assess for Eustachian tube dysfunction Valsalva’s maneuver to assess for fluid behind the ear drum Sinuses • Palpation of sinuses for signs of tenderness • Maxillary tooth sensitivity Posterior oropharynx Postnasal drip Lymphoid hyperplasia (“cobblestoning”) Tonsillar hypertrophy Chest and skin Atopic disease Wheezing
  • 15. Allergic Rhinitis management
  • 16. Most cases of allergic rhinitis respond to pharmacotherapy. Patients with intermittent symptoms are often treated adequately with oral antihistamines, decongestants, or both as needed. Regular use of an intranasal steroid spray may be more appropriate for patients with chronic symptoms. Daily use of an antihistamine, decongestant, or both can be considered either instead of or in addition to nasal steroids. The newer, second-generation (ie, nonsedating) antihistamines are usually preferable to avoid sedation and other adverse effects associated with the older, firstgeneration antihistamines. Ocular antihistamine drops (for eye symptoms), intranasal antihistamine sprays, intranasal cromolyn, intranasal anticholinergic sprays, and short courses of oral corticosteroids (reserved for severe, acute episodes only) may also provide relief.
  • 17. Goals of allergic rhinitis management Freedom from Symptoms Acute attacks and emergency hospital visits Frequent absenteeism from work/school Limitation of physical activity Adverse effects of drugs
  • 18. How is allergic rhinitis managed? step 1 : Avoidance & Environmental control step 2 : Antihistamine, Decongestant, Mast cell stabilizer step 3 : Corticosteroids step 4 : Immunotherapy
  • 19. TABLE-PHARMACOLOGIC OPTIONS FOR RHINITIS: EFFECTS ON SYMPTOMS Agent Sneezing Itching Congestion Rhinorrhea Eye Symptoms Oral antihistamines ++ ++ +/- ++ ++ Nasal antihistamines + + + + - Intranasal corticosteroid ++ ++ +++ ++ + Leukotriene modifiers + + + + + Oral decongestants - - ++ - - Nasal decongestants - - +++ - - Nasal mast-cell stabilizers + + + + -
  • 20. The following medications are used in patients with allergic rhinitis: Second-generation antihistamines (eg, cetirizine, levocetirizine, loratadine, desloratadine, fexofenadine) Intranasal antihistamines (eg, azelastine, intranasal olopatadine) Intranasal corticosteroids (eg, intranasal beclomethasone, intranasal budesonide, intranasal ciclesonide, intranasal flunisolide, intranasal fluticasone, intranasal mometasone, intranasal triamcinolone) Intranasal antihistamine/corticosteroid (eg, azelastine/fluticasone intranasal) Intranasal decongestants (eg, ipratropium intranasal) Intranasal mast cell stabilizers (eg, intranasal cromolyn sodium) Leukotriene receptor antagonists (eg, montelukast)
  • 21. Second-generation antihistamines Often referred to as the nonsedating antihistamines. They compete with histamine for histamine receptor type 1 (H1) receptor sites in the blood vessels, GI tract, and respiratory tract, which, in turn, inhibits physiologic effects that histamine normally induces at the H1 receptor sites. Some do not appear to produce clinically significant sedation at usual doses, while others have a low rate of sedation.
  • 22. Intranasal antihistamines Alternative to oral antihistamines to treat allergic rhinitis. Azelastine Use prn or on a regular basis. Use alone or in combination with other medications. Unlike oral antihistamines, has some effect on nasal congestion. Helpful for vasomotor rhinitis. Some patients experience a bitter taste. Systemic absorption may occur, resulting in sedation (reported in approximately 11% of patients). Olopatadine intranasal For relief of symptoms of seasonal allergic rhinitis. Before initial use, prime product by releasing 5 sprays or until fine mist appears. When product has not been used for more than 7 days, re-prime by releasing 2 sprays. Avoid spraying into eyes.
  • 23. Intranasal cromolyns Produce mast cell stabilization and antiallergic effects that inhibit degranulation of mast cells. Have no direct antiinflammatory or antihistaminic effects. Effective for prophylaxis. May be used just before exposure to a known allergen (eg, animal, occupational). Begin treatment 1-2 wk before pollen season and continue daily to prevent seasonal allergic rhinitis. Effect is modest compared with that of intranasal corticosteroids. Excellent safety profile and are thought to be safe for use in children and pregnancy. Cromolyn sodium Used daily for seasonal or perennial allergic rhinitis. Significant effect may not be observed for 4-7 d. For patients with isolated and predictable periods of exposure (eg, animal allergy, occupational allergy), administer just before exposure. Generally less effective than nasal corticosteroids.
  • 24. Intranasal corticosteroids: • Intranasal corticosteroids are highly effective in preventing and relieving nasal symptoms associated with both earlyand late-phase allergic responses. • In general, they relieve nasal congestion and itching, rhinorrhea, and sneezing, and in some studies they almost completely prevented late-phase symptoms. • Although some relief may occur within a few days, a full response to the drugs may take up to several weeks. Ref: 1. Mygind N. Glucocorticosteroids and rhinitis. Allergy 1993;48:476-90. 2. Onrust SV, Lamb HM. Mometasone furoate: a review of its intranasal use in allergic rhinitis. Drugs 1998;56:725-45.
  • 25. Leukotriene modifiers Use in children now widely approved for allergic rhinitis in children over 12 months. Few side effects-reported liver effects Drug interactions with theophylline, warfarin, terfenadine Oral formulations once daily Work to decrease leukotrienes and decrease inflammation Studies on montelukast alone or in combination with loratadine/ cetrizine/ levocetrizine is well tolerated and provides clinical and quality-of-life benefits for patients with seasonal allergic rhinitis
  • 26. Rationality of using combined Montelukast and Levocetirizine as Treatment for Allergic Rhinitis Antihistamines are effective in reducing pruritis, sneezing and watery rhinorrhea, and are a mainstay therapy for allergic rhinitis. Although first generation antihistamines are generally more effective in controlling rhinorrhea compared with second generation antihistamines, their use is markedly limited due to greater anticholinergic effects. Second generation antihistamines have shown favourable effect on sleep in patients with allergic rhinitis and are in general recommended for mild to moderate disease as first-line therapy, but not effective in nasal congestion. Ref: Camelo-Nunes IC (2006) New antihistamines: a critical review. J Pediatr (Rio J) 82: S173-S180.
  • 27. Montelukast serves a role in helping reduce symptoms of allergic rhinitis that are not controlled with antihistamines alone by competitively and reversibly inhibits cysteinyl leukotrienes (CysLTs), specifically leukotrienes D4 (LTD4), theoretically decreasing congestion and stuffiness associated with allergic rhinitis. Montelukast, as monotherapy has been effective in improving daytime and nighttime symptoms in patients with allergic rhinitis and in comparison to antihistamines appear to have significantly better improvement in night time symptoms. Ref:1. Philip G, Malmstrom K, Hampel FC, Weinstein SF, LaForce CF, et al. (2002) Montelukast for treating seasonal allergic rhinitis: a randomized, double blind, placebo-controlled trial performed in the spring. Clin Exp Allergy 32: 1020-1028. 2) Nayak AS, Philip G, Lu S, Malice MP, Reiss TF, et al. (2002) Efficacy and tolerability of montelukast alone or in combination with loratadine in seasonal allergic rhinitis: a multicenter, randomized, double blind, placebo controlled trial performed in the fall. Ann Allergy Asthma Immunol 88: 592-600. 3) van Adelsberg J, Philip G, LaForce CF, Weinstein SF, Menten J, et al. (2003) Randomized controlled trial evaluating clinical benefit of montelukast for treating spring seasonal allergic rhinitis. Ann Allergy Asthma Immunol 90: 214-222.
  • 28. Hence, a combination therapy of montelukast with antihistamines could provide enhancing and complementary effects, thereby reducing both the daytime and night time symptoms effectively. Combination of levocetirizine with montelukast has shown a significant improvement in patients with allergic rhinitis. There was a significant improvement in both daytime and nighttime symptoms in patients on combination therapy as compared to placebo and giving both the drugs as monotherapy. Ref: 1) Ciebiada M, Ciebiada MG, Kmieck T, Dumuske LM, Gorski P (2008) Quality of life in patients with persistent allergic rhinitis treated with montelukast alone or in combination with levocetirizine or desloratidine. J Invest Allergol Clin Immunol 18: 343-349. 2) Ciebiada M, Ciebiada MG, Dubuske LM, Gorski P (2006) Montelukast with desloratidine or levocetirizine for the treatment of persistent allergic rhinitis. Ann Allergy Asthma Immunol 5: 664-671.
  • 29. Intranasal anticholinergic agents Used for reducing rhinorrhea in patients with allergic or vasomotor rhinitis. No significant effect on other symptoms. Can be used alone or in conjunction with other medications. Ipratropium bromide (Atrovent Nasal Spray) is available in a concentration of 0.03% (officially indicated for treatment of allergic and nonallergic rhinitis) and 0.06% (officially indicated for the treatment of rhinorrhea associated with common cold). The 0.03% strength is discussed. Ipratropium ( Nasal Spray 0.03%) Chemically related to atropine. Has anti-secretory properties, and when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa. Poor absorption by nasal mucosa; therefore, not associated with adverse systemic effects.
  • 30. Thank you